Inspection on 05/03/07 for Howards

This inspection was carried out on 5th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Howards 24/09/08

Howards 27/09/07

Howards 08/12/05

Howards 16/08/05

Howards 20/12/04

Howards 13/08/04

Similar services:

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Howards Howards 24 Rowtown Addlestone Surrey KT15 1EY Lead Inspector Susan McBriarty Unannounced Inspection 08:15 5 March 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Howards Address Howards 24 Rowtown Addlestone Surrey KT15 1EY 01932 856665 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Greydales Limited *** Post Vacant *** Care Home 21 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (21), of places Sensory impairment (4) Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be 60 years and over. 8th December 2005 Date of last inspection Brief Description of the Service: Howards is a care home situated in a quiet residential area on the outskirts of Addlestone. The home provides care for twenty-one residents who are over 60 years of age. Registration of the home changed in February 2007 enabling the home to accept up to eight service users over 6o years of age who also have dementia Accommodation is arranged on two floors, with nineteen single bedrooms, fifteen with en-suite facilities and one double bedroom. Stairs or a shaft lift reaches the first floor. There are two lounges and a conservatory, which, is also the dining room. The conservatory overlooks a well maintained garden with a fish pond. There is off the road parking at the front of the premises. The fee level for 2006/2007 ranges from £500 to £550 per week. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection process includes reviewing documentation and information provided by the registered person, surveys of service users and relatives and a visit to the establishment. The visit to the establishment lasted approximately six and half hours (6.5) hours, commencing at 08:15am and ending at 2:45pm. Ms Susan McBriarty regulation inspector carried out the visit. The term “Resident” is used throughout this report as the preferred title, instead of “Service User”. The home has an acting manager who informed that she was in the process of being registered with the commission. The inspection took into account the pre-inspection questionnaire information and records held at the home including resident files, staff personnel files, training, medication administration and daily records. The inspector made observations of interactions between staff and residents during the visit and spoke with some of the residents and staff. The commission had received a total of 17 comment cards from relatives, residents or other sources (such as other professionals) by the time of the visit. The pre-inspection information was received during the visit. What the service does well: What has improved since the last inspection? The home has varied its conditions of registration to accommodate and care for up to eight service users with dementia. Two bedrooms had been redecorated and three refurbished. In addition the hall and room had been re-carpeted and new carpets and blinds provided. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 6 What they could do better: The home was advised by the commission as a matter of good practice to consider adding the job title of the person completing assessment records to confirm that a person competent to do so had completed the assessments. Care planning arrangements need improvement to ensure that the health, personal and social care needs of residents are set out in a plan that is up to date and ensure that documented, recorded reviews are carried out regularly. A previous requirement regarding care planning had not been met by the home. Significant improvement was needed to make sure risk assessments for daily living including the self-administration of medication were in place. This would ensure that residents health and safety was promoted and protected. Requirements made previously regarding the risk assessment of selfadministration of medication had not been met. The complaint policy needed minor updating to further confirm that residents and relatives complaints are taken seriously and acted upon. The policy and procedure for safeguarding adults needed to be developed and implemented. Some improvement was needed to the whistle blowing policy. This will confirm that residents are protected from abuse. The management of the home needs to regularly review the decoration, refurbishment, repair and provision of safety equipment for longer term residents in order to promote a well-maintained and safe environment for residents. Immediate attention was required in respect of one aspect of recruitment practice. The matter was dealt with immediately by the home and continues to ensure that residents are protected by the home’s recruitment procedures and practices. Some improvement in documenting and recording staff training and the provision of a training plan would confirm that staff are trained and competent to do their jobs and that residents are in safe hands at all times. The home needs to develop and implement a formal, documented and recorded system of quality assurance to ensure the home is run in the best interests of the residents. Policies and procedures developed and implemented by the home needed improvement to ensure they were up to date and that any legislative changes had been taken into account. Please contact the provider for advice of actions taken in response to this Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was assessed. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted to the home on the basis of a full assessment ensuring that the home does not take anyone whose needs they are unable to meet. EVIDENCE: Eight (8) residents said that they had received enough information about the home before they moved in. Evidence of trial visits being carried out and documented were seen during the visit. Feedback from five (5) relatives said that they were always welcomed into the home. The commission received no additional comments from relatives. A number of service user files were sampled; pre-admission assessments had been completed on all occasions. The assessments had been signed, in one instance the assessor was identified by their first name only and the remaining showed their full name. None of those sampled had recorded the role of the assessor within the home. Some of those sampled showed that relatives had been involved in the pre-admission assessment. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 10 As a matter of good practice the management of the home are advised to ensure that the role and therefore the responsibilities of members of staff carrying out pre-admission assessments is identified and recorded. This will reassure residents and identify to any external body that may require it information that an appropriate person had carried out the assessment. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement is necessary to ensure that the health, personal and social care needs of residents are met. EVIDENCE: Feedback from ten (10) residents said that six (6) always received the care they needed and four (4) usually received the care they needed. The comments made included ‘I like it here it is very homely’, ‘everyone here gets the best of care’ and ‘happy and pleasant home’. Two professionals provided feedback and said that the home understood the care needs of the residents and that they were satisfied with the overall care provided. Feedback from five (5) relatives said that they were satisfied with the overall care provided, were able to visit their relative in private and were consulted about the care being provided by the home. A number of care plans were sampled. None of the care plans had been reviewed or updated since the admission of the service user. In one instance Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 12 the resident had been admitted for respite care and later moved to a become a permanent resident, this was not reflected in the information available. The acting manager said she was about to organise a meeting at the home with nominated members of staff in order to review the care plans. Following the inspection the provider informed the commission that care plans had been reviewed and updated regularly and that if there is no change the care plan remains unchanged. The commission were also informed that in future the home would date each of the reviews carried out. The requirement made during the inspection of 8th December 2005 to ensure that all service users have a current and up to date care plan had not been met. Letters and other information from various health professionals were held in service users files identifying a number of health care needs. The daily records viewed showed that residents had accessed health care professionals such as doctors and chiropodists. However it could not be confirmed that all residents health needs had been identified and met, as the care plans could not be confirmed as being up to date. A further requirement is made to make sure that care plans are current and accurate, and that documented, recorded reviews take place regularly. The National Minimum Standard is that monthly reviews take place. One resident was identified in the daily records as being aggressive to members of staff, a risk assessment had not been completed to make sure that the resident and members of staff were safe. The home had a policy and procedure for working with aggression however this said that members of the care staff were to inform the nurse in charge and that restraint may be used as a ‘last resort’. The policy did not reflect the practice of the home and care staff had not been trained to carry out restraint. Please see the Staffing and Management sections of this report. The administration of medication was reviewed. The inspector made observations during the visit that confirmed that medication was administered appropriately. The medication records in use had just been replaced with new records, however previous records were held in resident files and no evidence was found of gaps or errors in administration. A procedure for the administration was available. The procedure set out what members of staff were required to do when administering medication. The procedure did not include carrying out risk assessments for those self-administering or what action must be taken when receiving or disposing of medications. The management are advised that the addition of this information to the procedure for the administration of medication would assist in directing members of staff. Two residents had been supported by the home to continue to self-administer medication and maintain their independence. The acting manager confirmed that risk assessments including the self-administration of medication had not been carried out. Following the inspection the provider informed the Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 13 commission that one resident had a risk assessment completed on 24th August 2005 and the other had an agreement in place. Requirements made during the inspections of 16th August 2005 and 8th December 2005 for the home to carry out risk assessments for the selfadministration of medication had not been met. A further requirement is made to ensure that documented, recorded risk assessments for daily living, including the self administration of medication are completed, reviewed regularly and where possible signed by the resident or their representative, in order to promote and protect the safety and well being of residents. Please also see the environment section of this report. The list of staff able to carry out the administration of medication had a number of names crossed out. The acting manager confirmed that those members of staff no longer worked at the home. The management of the home are advised to re-write the list to remove the names of staff no longer working at the home to ensure the list remains clear and up to date. The pre-inspection questionnaire noted that training for the administration of medication was planned. Please also see the Staffing section of this report. The recording and documenting of information in an appropriate format and observations made during the visit confirmed that residents were treated with respect and their right to privacy was upheld. Records and documents were held in the manager’s office, members of staff were observed treating service users with respect. One bedroom was not viewed during the tour of the home as the manager and proprietor considered that the service user would not appreciate the intrusion. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a balanced diet in pleasant surroundings and have access to activities to meet recreational, social and personal needs. Some work in documenting activities would further improve the provision of activities. EVIDENCE: The pre-inspection questionnaire documented that activities such as quizzes, visiting entertainment, an annual trip out, board games and similar were provided by the home. The information provided also said that access to a day centre was available. Feedback from ten (10) residents said that six (6) felt activities were sometimes available, three (3) activities were usually available and one (1) said they were always available. The management team of the home including the acting manager and provider said that a number of activities took place within the home. The inspector was informed that two of the management team had attended a local group Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 15 supporting people with Alzheimer’s in order to gain ideas about suitable activities for people with dementia that may be used in the home. A separate record of activities was not kept by the home. The record would assist the home to confirm which service users had attended those activities available. The documenting and recording would also confirm that resident views and wishes were taken into account and whether an activity was worthwhile to the residents. A recommendation is made. Discussion with the cook, residents spoken with during the visit, observations made by the inspector during the visit and menus supplied by the home confirmed that a varied menu is provided. The cook said that a choice was not given for the main meal although if the meal was not liked an alternative would be provided. In addition the inspector was informed that the residents prefer plain meals although a pasta dish had been tried recently and the cook said this had been reasonably successful. On the day of the visit the inspector observed fresh ingredients being used for the main meal. Feedback from ten (10) residents said that five (5) always liked the meals provided and five (5) usually liked the meals. Consideration should be given to offering a choice of main meal in order to improve this feedback from residents and to take account of National Minimum Standards. Lunch was taken in the dining area and was observed to be a quiet time with only some of the residents choosing to chat to others. The pre-inspection record documented that only one resident needed prompting or support to eat a meal. Those observed by the inspector during the visit were able to eat independently. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives could be confident that their complaints would be listened to, taken seriously and acted upon. Improvement is needed to make sure a policy and procedure was in place to ensure residents are protected from abuse. EVIDENCE: The home had a complaints procedure in place. The procedure needed minor updating to recognise the change to the Commission for Social Care Inspection. The revision would also be an opportunity for the home to note the change of address of the commission. Feedback from five (5) relatives documented that two (2) had made complaints although no detail was given. Two (2) professionals provided feedback; one (1) said they had not received any complaints about the service and one (1) made no response. Feedback from ten (10) residents and five (5) relatives said that all but one was aware of how to make a complaint. Ten (10) residents also said that they would know who to talk to if they were not happy. One said that ‘staff were helpful’. Residents and their relatives can be confident that their complaints will be listened to, taken seriously and acted upon. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 17 The pre-inspection questionnaire documented that the home’s procedure for safeguarding adults had been updated on the 3rd October 2005. However during the visit the acting manager confirmed that the policy and procedure could not be found. A copy was not available electronically as none of the home’s policies and procedures had yet been copied onto a computer. The acting manager had reviewed the local policy and procedure of a sister home in order that consideration was given to using the same one in this home. The policy and procedure was viewed by the inspector and was found not to reflect the local authority guidelines for safeguarding adults. A requirement is made for a policy and procedure to safeguard adults to be in place and that it reflects the local authority guidelines and national guidance. The home’s whistle blowing policy and procedure was viewed. The policy does not identify what action must be taken should a whistle blower identify safeguarding matters. The policy stated that the provider would investigate all matters raised unless they were criminal. A requirement is made that the whistle blowing policy be reviewed and updated and a statement added to confirm that any safeguarding matter would be dealt with under the local authority multi-agency procedures for the protection of adults. These actions will ensure that residents are safeguarded from abuse. Staff training took place although it was not possible to confirm that all members of staff had received training regarding the safeguarding of adults. Please see the Staffing section of this report regarding training matters. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and hygienic however some improvement was needed to ensure the home was safe and well maintained EVIDENCE: A tour of the home took place and all areas except for one bedroom were viewed. The acting manager and provider informed the inspector of the resident’s wishes for the bedroom not to be seen without their presence and direct permission. This confirmed that the home respected the wishes and choices of residents. The pre-inspection questionnaire stated that two bedrooms had been redecorated, three bedrooms supplied with new furniture and new flooring in some areas of the home. The information confirmed that given by the acting Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 19 manager during the visit. The acting manager said that bedrooms were generally redecorated as they became vacant. It was unclear how often a bedroom would be redecorated if a resident were staying at the home for some years. Some bedroom walls had cracks in them. The provider said the cracks had appeared as the plaster had dried out. The acting manager said that a request had been made for redecoration of the communal areas. The request had not yet been agreed. The home did not have a plan setting out how often redecoration and refurbishment would take place. Adequate bathroom facilities were provided although a number of residents preferred to use the walk in shower provided on the ground floor. A small amount of water had pooled by the entrance to the dining area/conservatory, the management team of the home were aware of this matter and said that action had been taken for the issue to be attended to. A risk assessment was in place stating that all the first floor windows had been fitted with window restrictors, this was not the case. A number of windows on the first floor were found without any form of restrictor being in place. The provider checked this matter during the visit. The management are advised that the risk assessment needs some revision to reflect individual residents needs. A recommendation is made that the home review the need to provide a plan of redecoration, refurbishment, repair and provision of safety equipment to ensure that longer stay residents, live in a well maintained environment. The garden area was viewed. Residents were able to access the garden either through the conservatory or an entrance at the front of the home. The home also had an entrance at the rear of the garden. Some areas of the garden were uneven and may be a potential hazard to service users. A large fishpond was in place and a risk assessment had been completed to take into account safety matters. Feedback from ten (10) residents said that seven (7) had a physical disability and one (1) had a visual impairment. Risk assessments should take these disabilities into account. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 20 The home was found to be fresh and hygienic during the visit. Feedback from ten resident found that six (6) said the home was always fresh and clean and four (4) said the home was usually fresh and clean. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are not fully supported and protected by the home’s recruitment policy and practice. Some improvement in record keeping with regard to staff training would confirm that members of staff are trained and competent to do their job. EVIDENCE: As noted in the summary of this report the pre-inspection questionnaire was received during the visit to the home and the content reviewed by the inspector following the visit. The rota provided by the home as part of the pre-inspection questionnaire indicated that between four (4) and five (5) care staff were on duty from 8am to 2pm each morning, including the acting manager or deputy manager. From 2pm the staffing levels, including the management of the home generally reduced to between four (4) and five (5) including a ‘supper assistant’ from 5pm to 8pm. Two night staff were on duty from 8pm to 8am each day. The home provides for up to twenty one (21) service users. All the care staff were female and three of the service users were male. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 22 The pre-inspection questionnaire said that of the eleven (11) care staff four (4) have a National Vocational Qualification of Level 2 or above and four (4) were undertaking qualifying training. One member of staff spoken with confirmed that they were undertaking the qualifying training and hoped to complete the course within the time recommended. Four (4) staff files were sampled. All but one (1) of the files sampled had a copy of the CRB check confirming the statement made by the manager. The acting manager said that a CRB application had been made regarding the one member of staff. A protection of vulnerable adults check (PoVA) had not been made prior to the member of staff starting work. Following the visit the commission viewed the pre-inspection questionnaire and the document identified other members of staff for whom a CRB application may not have been made. The information provided in the questionnaire did not confirm whether PoVA checks had been requested and received prior to those staff starting work. An immediate requirement was made during the visit and followed up in writing to ensure that no member of staff starts work at the care home unless a satisfactory PoVA check is received. The satisfactory PoVA check enables staff to begin work until such times as a full and satisfactory CRB check is returned. Following the inspection the commission received written conformation from the provider stating that the matter had been dealt with appropriately. A recommendation is made that the home reviews their policy and procedure with particular reference to storage, recording and disposal of criminal record bureau checks in line with the Criminal Record Bureau guidance. The staff application form asks for career details starting with the most recent. A requirement is made to make sure that the application form requests a full employment history with the reason for any gaps in employment. Some training certificates were held in staff files and some files indicated the training completed on the front of the folder. Certificates for some staff who had completed training in dementia and food hygiene arrived by post during the inspection. One member of staff informed the inspector they had yet to take in their certificates to confirm completion of training to the home. The acting manager confirmed that the home did not have a central training record that could be referred to and identify any gaps in training. It was not possible Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 23 to confirm that all members of staff had completed all the required training without analysing all the information available. A recommendation is made that the home develops a training plan to inform of training completed and when next due. This would confirm that members of staff are trained and competent to do their job and ensure that residents safety, health and well being are protected. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,34 and 38 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The policy and practice of the home does not fully promote and protect the safety, health and well being of residents and ensure that it is run in their best interest. EVIDENCE: The acting manager said she had been in post for five months, the preinspection questionnaire confirmed a start date of 2nd October 2006. The acting manager said that application for registration with the commission had started and she had made application for CRB check. This was her first post as a manager. The acting manager said she was also undertaking the registered managers award as part of their training for the post of registered manager. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 25 The pre-inspection questionnaire stated that the home had an annual development plan for quality assurance last reviewed in 2002. During the visit the commission viewed the policy for quality assurance and found that the quality assurance policy is a statement of intent to provide a quality service. Following the inspection written confirmation was received from the provider that stated that the home’s quality assurance process was one of ‘walking the floor’ and ‘using the seeing eye’. This is a Key Standard, and a requirement is made for the home to develop a formal, documented and recorded quality assurance system in accordance with National Minimum Standards and that outcomes are given to residents and their relatives to confirm that the home is run in the best interests of the residents. The pre-inspection questionnaire documented that two (2) residents maintain their own finances and that the home does not act as appointee for any resident. It was identified with the acting manager and provider that the home records the expenditure of a number of resident and this amount is then invoiced to the person/s paying the invoice for the care provided. In some instances cash was given to the home by relatives for some residents to access. A number of finance records were sampled during the visit. The records relating to expenditure were found to be accurate. Accident and incident reports were checked and records had been adequately kept by the home. Information confirming that health and safety checks had been carried out by the home was received in the pre-inspection questionnaire. These included fire equipment checks, visit from an environmental health officer in April 2006, emergency lighting check in January 2007 and call systems check in January 2007. The pre-inspection questionnaire and information viewed during the visit identified that a number of policies and procedures provided by the home had not been reviewed for some time. For example the pre-inspection information completed by the acting manager and provider stated that the home has a health and safety policy but not when it was last reviewed. Continence promotion had not been reviewed since 1998, accidents to residents and staff was last reviewed in 1997 and physical intervention and restraint in 2002. A requirement is made for the home to review and update policies and procedures and to ensure legislative changes, where necessary, is taken into account. For example the use of restraint training for members of staff must be by an accredited trainer. This will ensure that the health, safety and well being of residents and members of staff is promoted and protected. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 26 The matters raised in this report which include concerns regarding, care planning, risk assessment and the need to develop a robust formal quality assurance system detract from otherwise adequate administration and management systems. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 2 X X X 2 Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must be updated and reviewed regularly according to residents’ needs and taking the National Minimum Standards of monthly reviews into account. Timescale from the inspection of the 8th December 2005 had not been met. Risk assessments must be carried out taking into account all daily living activities including the self-administration of medication, mobility, falls, window restrictors and access to the garden. Timescale from the inspection of the 8th December 2005 regarding risk assessments not met. Timescales from the inspections of 16th August and 8th December 2006 regarding the self administration of medication not met. Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 29 Timescale for action 31/08/07 2. OP7 13(4) 30/06/07 3. 4. OP16 OP18 22 13(6) 5. OP18 13(6) 6. OP29 19(10) (11) 7. OP33 24 8. OP38 13(4) The complaint policy must provide accurate details of the name of the commission. A policy and procedure for safeguarding adults must be developed and implemented and reflect the local authority guidelines. The whistle blowing policy must be reviewed to ensure that it includes a statement confirming that any safeguarding matters will be referred under the local authority multi-agency safeguarding procedures. No member of staff must begin working at the home without either a satisfactory CRB check and/or a satisfactory PoVA check. The home must develop and implement a formal system for documenting and recording quality assurance taking into account National Minimum Standards. The policies and procedures implemented by the home must be reviewed and updated taking into account any legislative and good practice changes, including dealing with aggression, health and safety, physical intervention and continence promotion. 30/06/07 31/07/07 30/06/07 05/03/07 31/08/07 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations It is recommended that the home provide a separate document to record which service user attended which DS0000013683.V330031.R01.S.doc Version 5.2 Page 30 Howards 2. OP19 activity and when. This will assist the home in making sure the activities provided continue to meet the needs and wishes of the service users. It is recommended that the home introduce a plan of redecoration, refurbishment, provision of safety equipment and repair setting out when longer term service user bedrooms are expected to receive attention. This would confirm that service users live in a safe and wellmaintained environment. It is recommended that the home review the guidance provided by the Criminal Record Bureau with particular regard to recording, storage and disposal of information. It is recommended that the home introduce a system for the recording of training that enables the management team to easily identify any gaps in the training needs of members of staff. This would confirm that service users are supported by staff who are trained and competent to do their jobs. 3. 4. OP29 OP30 Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Howards DS0000013683.V330031.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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